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CLINICAL CORNER Clinical Consultation, A Personal Perspective: Components of a Successful Integrative Medicine Clinical Consultation Moshe Frenkel, MD Integrative medicine is becoming an increasingly popular and visible component in oncology care. Thus, the question arises: How can clinicians facilitate, encourage, and integrate the use of complementary and integrative medicines (CIMs) in patients with cancer? The integrative medicine consultation is not easy and involves much more than simply providing reliable information about the proper use of CIM therapies to alleviate symptoms. Some key factors are necessary to allow for a successful consultation for patients and their families and caregivers: physicians must have extensive knowledge of CIM and of cancer care; they must use a sensitive approach in communication with the patient that relies on effective communication skills and experience in listening; and they must have the ability to convey empathy and compassion. Key words: alternative medicine, cancer care, complementary medicine, integrative medicine, medical education, patient-doctor communication n the past few years, the term integrative medicine has become more prevalent in medical academia. The Consortium of Academic Health Centers for Integrative Medicine defined this term as "the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed hy evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing."' This general definition relates to the actual process of delivering this type of care. / Although applying the concept of integrative medicine to cancer care is still in its infancy, a few comprehensive cancer centers in the United States are trying to put these concepts into practice. As a result of this growing interest in integrative medicine in cancer care, the Society of Integrative Oncology (SIO) was established. In its mission statement, the SIO describes itself as being dedicated to studying and facilitating cancer treatment and recovery through the use of integrated complementary therapeutic options, including natural and botanical products, nutrition, acupuncture, massage, mind-body therapies, and other complementary modalities.^ A question that comes Reprint requests: Moshe Frenkel, MD, Integrative Medicine Program, The University of Texas M. D. Anderson Cancer Center, 1515 Holcomhe Blvd, Houston, TX 77030; e-mail: [email protected]. DOI 10.2310/7200.2008.0017 to mind, however, is how can clinicians actually facilitate, encourage, and integrate the use of these complementary therapies in patients with cancer? What should a physician evaluate and discuss to address patients' concerns and needs? This issue is more complex than simply examining how and at what dosage a particular herb should be used or how it can be added to a long list of conventional regimens with which a patient is already being treated or what acupuncture points to use for a specific treatmentrelated symptom. Patients' Issues We should always bear in mind that patients with cancer are facing an existential crisis. Cancer is a disease that still cannot be cured in just under half of patients with cancer. Furthermore, patients with cancer face completely different internalization processes than do those with other chronic conditions, such as cardiac disorders, even when survival expectations are similar for both. Patients with cancer at times experience extreme fear, worsened by the uncertainty of recovery, and face a heightened awareness of their mortality that is more pronounced as this disease progresses. This is heightened by the awareness that, in many cases, the etiology of the disease is unknown, and patients struggle to make sense out of the traumatic diagnosis and the life-altering changes that subsequently take place. Journal ofthe Society for Integrative Oncology, Vol 6, No 3 (Summer), 2008: pp 129-133 129 130 Journal ofthe Society for Integrative Oncology, Summer 2008, Volume 6, Number 3 Another factor that makes the situation even more complex is the lack of communication between physicians and patients around the issue of complementary and integrative medicine (CIM). We know that 50 to 80% of patients use complementary medicines; however, many patients report that they do not think it is important for their physicians to know about this use, and many physicians do not ask about CIM use.^"^" In most cases, patients who use CIM are not disappointed or dissatisfied with conventional medicine, but they want to do everything possible to regain their health and improve their quality of life. ""^^ Patients may use CIM to reduce adverse effects, to protect and stimulate immunity, or to prevent further cancer recurrences. The extensive use of CIM by patients with cancer, however, can challenge and frustrate physicians as well as patients. This becomes especially apparent when the physician's knowledge of CIM is limited or when the patient cannot discuss CIM with the physician, possibly owing to the patient's perception that the physician has an indifferent or negative opinion of CIM.^*'^° This bilateral frustration can result in a communication gap between patients and physicians and is another reason that patients often do not tell their physicians about their use of CIM Communication as a Key Element An open dialogue between patients and medical staff is crucial to bridging the communication gap. To be open to patients' perspectives and sensitive to patients' need for autonomy and empowerment, physicians may need to shift their own perspectives.^^ Physicians should create an open, trustful dialogue by simply asking their patients about CIM use and being willing to respectfully listen to the answers without prejudice or judgment. Today's informed patients value physicians who appreciate them as empowered participants in their own health care choices; many patients view physicians and other health care providers as informed intermediaries, expert guides, and consultants in aiding them to regain their health or, better yet, maintain health (Table 1). Ultimately, physicians should encourage patients to be engaged in the decision-making process after advising them to the best of their knowledge. It is also appropriate for physicians to ask patients about their use of CIMs and for patients and their physicians to decide together on therapeutic management options at each stage of cancer care, from prevention, to acute care (radiation, chemotherapy, or surgery), to follow-up care (survivorship Table 1. Important Elements in the Integrative Oncology Consultation 1. Empathie communication with compassion and care 2. Provide adequate information and knowledge from reliable sources about these therapies 3. Provide psychological, social, and spiritual support 4. Empower patients and their families 5. Enable patients to develop strategies for living with cancer and support them in the process issues, follow-up visits, and prevention of recurrence). The main purpose of this early patient-physician discussion is not to prove or disprove the efficacy of CIM treatments but to sharpen and refine the answers to questions that may come up when patients and physicians are faced with uncertainties about therapies. Asking the right questions at the right time, particularly when definitive answers are not available, leads to improved patient-physician communication and to a rational strategy to address patients' needs and expectations in the face of uncertainty. To help cancer patients be truly informed and autonomous, physicians need to do the following^^: 1. Learn about conventional treatments that have been tried, have failed, or have been rejected because of safety, quality of life, cost, or other issues 2. Discover the levels of support that the patient relies on from family, community, faith, and friends 3. Ask patients about their use of CIM or interest in using CIM 4. Identify the patient's beliefs, fears, hopes, expectations, and experience with CIM 5. Acknowledge the patient's spiritual and religious values and beliefs, including views about quality-of-life and end-of-life issues, and seek to understand how these issues affect health care choices Content of CIM Consultation in Cancer Care Only after opening this route of effective communication can we move to the next steps of actually delivering information and addressing patients' concerns. Because some CIM therapies interact negatively with conventional care, physicians need to be aware of the therapies patients are using and provide a reliable response concerning this 24,25 use. In addition, physicians need to understand why patients with cancer use CIM therapies in the first place. Patients tend to use these therapies in anticipation of psychological support and because they want to do Frenkel, Personal Perspective on Clinical everything possible to feel hopeful, get more control in decision making, enhance the immune system, use less toxic treatments, or reduce adverse effects and possible toxicity. In fact, most patients choose CIM to improve their quality of life rather than expect a cure by its use.'*"" With these reasons in mind, what are the components of a successful integrative medicine consultation? Based on patients' individual concerns and making appropriate modifications, such a consultation should include four crucial points: 1. Adequate knowledge from reliable sources about CIM therapies the patient is using or considering using 2. Psychological, social, and spiritual support 3. Empowering patients and families 4. Patients who are able to develop strategies for living with cancer who are supported by their physicians during the process To address these points, physicians need to pay attention to patients' psychological as well as physical needs, provide an environment in which patients can easily disclose their concerns, and try to facilitate patient involvement in the decision-making process (Table 2). As addressing these issues requires time and knowledge, most oncologists in the current health care system cannot provide this kind of consultation. In fact, most cancer centers that offer integrative oncology consultations use a referral process in which an integrative medicine physician dedicates time to discuss these issues in more detail and in a setting other than the primary oncology clinic. History and Physical Status Integrative oncology consultations require an understanding of the patient's current physical situation. Specifically, is the patient coming for consultation during radiotherapy or chemotherapy? What type of chemotherapy is involved? Table 2. Content of Integrative Oncology Consultation 1. Conventional history and physical 2. Explore previous and current use of complementary and integrative medicine (previous use, current use, and the patient's desire for future use) 3. Explore patient concerns 4. Search the literature to address patient concerns as well as nutrient/herbal/drug interactions 5. Provide adequate balanced information 6. Develop a plan that the physician, patient, family, and caregivers can agree to 7. Follow up to verify progress and clarify additional concerns Consultation 131 What current physical and emotional problems is the patient or caregivers encountering? The history and physical are a critical first step in the integrative oncology consultation. At times, a patient comes to such a consultation with very high expectations while neglecting important signs and symptoms that require immediate attention as part of the conventional approach. For example, a patient who is looking for herbs or supplements to counteract extreme fatigue may actually have developed severe anemia and require a transfusion. Exploring CIM Use After reviewing a patient's conventional medical history and performing a basic physical examination, physicians need to explore the type of complementary therapies being used; these therapies should be described at a level of detail comparable to that of the medication lists that are updated while taking a routine medical history. They also need to unravel the often complicated reasons why patients are using these therapies or wanting to use these therapies. The use of complementary therapies is at times related to patients' strong beliefs, environment, family, culture, religious orientation, and other spiritual values. The source of information that influenced patients' use of these therapies and the patients' relationship to this source are equally important and probably relate to these issues. Physicians need to explore patients' beliefs and values because they are strongly associated with the strength of patients' commitment to the use of complementary therapies. Patients can often have a surprisingly strong emotional belief about the CIM therapies. If physicians fail to notice these associations, patients may neglect or ignore physicians' advice. It is crucial to explore this issue with patients and their families and caregivers since they play an important role in the comphcated process of decision making. In addition, examining patients' use of CIM before diagnosis can at times help predict the use of CIM after diagnosis and patients' level of commitment to CIM. If patients have had positive experiences using CIM for other minor ailments, chances are good that they wiU use CIM during their cancer treatment. Exploring the expectations from CIM use helps clarify the picture and is important to devising a proper plan. As mentioned before, another important aspect of the consultation is addressing the need of patients' famuy and caregivers, who sometimes need to be involved in the treatment. The role of the famOy and caregivers should be 132 Journal of tbe Society for Integrative Oncology, Summer 2008, Volume 6, Number 3 emphasized as they are often the key decision makers. More often than not, they, too, need support and empowerment. An effective exploration of CIM use requires a very sensitive approach that depends on effective communication skills, experience in listening, and the ability to convey empathy and compassion. These last two elements are quite critical ingredients in this involved interaction. Empathy denotes a deep emotional understanding of another's feelings or problems; it is a mental and affective projection into the feelings or state of mind of another person and an involved process that combines both cognition and emotion. Compassion appears to augment this process; it is the humane quality of understanding the suffering of others and wanting to do something about it, it is not simply a sense of sympathy or caring for the person suffering, and it is a sustained and practical determination to do whatever is possible and necessary to help alleviate patients' suffering. Compassion is not true compassion unless it is active.^'' Providing Knowledge Physicians agree that supporting patients with cancer is crucially important. However, patients must be given appropriate information from reliable sources. Although information is available on many CIM therapies, for many, information is not readily available; in fact, some CIM therapies must be extensively investigated so that adequate information can be obtained that will help patients make informed decisions. At times, practitioners need to research and even visit manufacturers of supplements that they elect to use or recommend to their patients. In the United States, about 20,000 types of nutritional supplements are sold. If a patient believes strongly in the use of a specific supplement or other CIM therapy, the physician needs to make an effort to explore the use of this treatment. Even if initially a particular treatment seems bizarre or to have no scientific justification, the physician should not dismiss its use without making a sincere effort to obtain information that can be useful to the patient. A physician's simple dismissal of the use of a specific CIM therapy, especially when the patient has a very strong belief in the treatment's value, could lead to mistrust, the patient ending up using a treatment that should not be used, and even a lack of compliance with conventional care. To provide the kind of information the patient needs, the physician should perform a search of the literature, which can involve, but is not limited to, scientific literature. Sometimes a critical review of marketing information, electronic databases, discussions with experts in the field, and other sources needs to be used creatively. This search of the literature should first emphasize the known or speculated safety of the CIM therapy in question, in keeping with the first law in medicine, Primum non nocere—"First, do no harm." Second, the physician should look for clues about the effectiveness of the treatment; sources might include case reports, cohort studies, epidemiologic data, in vitro studies, and animal studies if other research studies of stronger value cannot be found. At times, there is a need to review possible interactions with conventional treatments. At other times, a review of the patient's nutritional intake may be necessary to address deficiencies or to make suggestions for improvement. This review can be supported by professionals, such as a pharmacist or dietitian, who have an interest in this topic. An objective and balanced discussion of the findings from this search will lead to trust and improve the delicate relationship needed in the consultation process. This discussion is crucial to building a treatment plan that the patient and their caregivers are actively involved with and committed to. In summary, physicians need to understand that most patients with cancer come to the integrative oncology consultation with intense emotions and are experiencing a tremendous existential crisis that cannot be ignored. This consultation, far from being easily administered, consists of more than providing reliable information about the proper use of CIM therapies to alleviate symptoms. For this consultation to be effective and useful to patients and their families and caregivers, it requires a very sensitive approach that depends on effective communication skills, experience in listening, and the ability to convey empathy and compassion. References 1. Consortium of Academic Health Centers for Integrative Medicine. Definition of integrative medicine. Available at: http://www. imconsortium.org/cahcim/about/home.html (accessed October 21, 2007), 2. 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